Final Assessment. Psychosocial Integrity.

The nurse in the outpatient psychiatric unit is returning phone calls. Which client should the psychiatric nurse call first?

A nurse caseworker suspects older adult neglect. What assessment findings during a home visit would confirm this? Select all that apply.

The nurse is about to conduct an admission assessment on an 85-year-old female client who is admitted after falling down in her home. When determining the amount of time to set aside for the interview, the nurse will consider which of the following?

The nurse notes that the client is quite suspicious during an assessment interview and believes her family is under investigation by the Central Intelligence Agency (CIA). What would be appropriate nursing interventions for this client? Select all that apply.

A client experiencing severe depression is admitted to the inpatient psychiatric unit. During the initial assessment, she says, “I feel like killing myself, but I wouldn’t do that because of my kids.” What action is the nurse’s priority?

A client diagnosed with schizophrenia tells the nurse. “There are voices outside the window telling me what to do all the time. Can you hear them? What should I tell them?” How should the nurse respond initially?

When caring for a client admitted for medically monitored detoxification from alcohol, the nurse would assess which of the following signs and symptoms of withdrawal?

A client with a diagnosis of schizophrenia repeatedly states, “There are flies eating my brain and making me feel weird.” The client is most likely experiencing which of the following?

A client hospitalized in a mental health unit is restrained after becoming extremely violent. Which finding indicates to the nurse that the client can be removed from the restraints?

When preparing a client for electroconvulsive therapy (ECT), the nurse would include which of the following actions?

Which of the following describes how cultural diversity may affect a client’s health?

The nurse is conducting an admission assessment interview with an adult Native-American client. Which therapeutic approach would be most effective?

A woman is diagnosed with highly disseminated, metastatic breast cancer. What will the nurse expect her initial reaction to be at the time the physician gave her the prognosis?

A client experienced the sudden onset of blindness, but extensive testing revealed no organic reason that the client could not see. The nurse later learned that the blindness developed after the client witnessed a fire at a neighboring house in which the family of three died. Which problem should the nurse suspect?

A client hospitalized with schizophrenia says to the nurse, “Get your goat. Go out and vote. Don’t be a cut throat. Row your boat.” How should the nurse document the client’s behavior?

A client comes to the nurses’ station and is upset and verbally abusive when told that her privileges to walk on the grounds have been canceled. What would be the most effective approach by the nurse?

Which patient is the most likely candidate for outpatient depot antipsychotic therapy?

A male-to-female transgender patient (transwoman) is admitted to an acute care psychiatric unit for depression and suicidal ideations. On her arrival, several other patients display suspicion and contempt and verbal harassment is directed toward the woman. What should the charge nurse do first?

A client with the diagnosis of acute pyelonephritis who is very shy and modest is scheduled for a voiding cystourethrogram. Why would the nurse determine that this client would benefit from increased support and teaching about the procedure?

A female client with the diagnosis of mania emerges from her room topless while making sexual remarks and lewd gestures toward the staff and her peers. Which action would the nurse take first?

After cardiac surgery to treat coronary artery disease, both the client and the family express anxiety regarding how to cope with the recovery process after discharge. Which available resource would the nurse plan to tell the client and family about to best address their concerns?

A client who is scheduled for permanent transvenous pacemaker insertion states to the nurse, “I know I need it, but I’m not sure this surgery is a great idea.” Which nursing response would best help the nurse assess the client’s preoperative concerns?

While conducting an initial assessment of an infant, a home health nurse notices that the infant is wearing a soiled piece of braided yarn around the neck. Which action by the nurse is most appropriate?

A client with superficial varicose veins states to the nurse, “I hate these things. They’re so ugly. I wish I could get them to go away.” Which therapeutic response would be most appropriate for the nurse to make to the client?

A nurse is caring for a client with agoraphobia. Which signs and symptoms would the nurse anticipate? Select all that apply.

An 8-year-old child, diagnosed with obsessive-compulsive disorder, is admitted by the nurse to a psychiatric facility. During the admission assessment, which behaviors would be characterized as compulsions? Select all that apply.

A rehabilitation nurse is caring for a young client recovering from a motor vehicle accident in which he lost both legs. The client states, “I will never be able to work again or live a normal life.” Which responses by the nurse would be considered therapeutic? Select all that apply.

A nurse is caring for a client diagnosed with persistent depressive disorder. Which defining characteristics are associated with this disorder? Select all that apply.

The charge nurse is caring for clients in an acute care psychiatric unit. Which client would be most appropriate for the charge nurse to assign to the licensed practical nurse (LPN)?

The male client admitted to the medical unit after a motor vehicle accident (MVA) admits using heroin. The unlicensed assistive personnel (UAP) tells the RN the client is really agitated and anxious and has slurred speech. Which intervention should the nurse implement first?

A nurse has developed a therapeutic relationship with a client who has an addiction disorder. Which client behaviors would indicate that the therapeutic interaction is in the working phase? Select all that apply.

The mental health worker (MHW) reports to the RN psychiatric nurse that two clients were kissing each other while watching the movie in the lobby area. Which action should the nurse implement?

A client is transitioning to a less intensive level of outpatient treatment for addiction. The nurse concludes the client is most at risk for relapse after the client makes a statement reflecting which theme?

What statement made by the mother of a recovering compulsive Internet user would indicate the need for more teaching?

Which of the following approaches would be best for the nurse who is communicating with the cognitively impaired client? Select all that apply.

A client with a terminal illness states, “If I could only live until I can walk my daughter down the aisle at her wedding, I will donate all of my money to research.” The nurse reports that the client is in which phase of the grief process?

The RN is caring for children in a psychiatric unit. Which client requires immediate intervention by the psychiatric nurse?

The nurse is working in an outpatient mental health clinic and returning phone calls. Which client should the psychiatric nurse call first?

Which client should the psychiatric clinic nurse assess first?

The nurse is caring for a client with severe depression. In which conditions would the nurse anticipate the use of electroconvulsive therapy (ECT) as an option? Select all that apply.

A client with a medical illness tells the nurse that going to church is not a priority. Based on this information, what should the nurse do at this time?

A client reports having difficulty concentrating and is having outbursts of anger, as well as feeling “keyed up” all the time. The client reveals that the behaviors began soon after witnessing the murder of a good friend. The nurse should suspect which stressor before communicating with the client?

A client states to the nurse, “I can’t get any help with my care! I call and call, but the nurses never answer my light. Last night one of them told me they had other clients besides me! I’m very sick, but the nurses don’t care!” Which statement by the nurse addresses the client’s primary concern?

While assisting with bathing, the client who has sustained a spinal cord injury states, “I can’t do this. I wish I were dead.” Which therapeutic response would the nurse make to encourage communication?

The nurse is caring for an 11-year-old child who has been physically abused. Which therapeutic action would the nurse include in the plan of care?

The nurse is caring for a client with catatonic schizophrenia. The client refuses to eat. What is the best nursing action?

A mental health client reports to the nurse that the television is talking to her in a threatening manner. What is the nurse’s best response to the client’s verbalization about the television?

The client was admitted to the psychiatric hospital with a history of increasing suspicion and hostility. During the admission interview, the client tells the nurse he knew he was followed to the hospital by spies hired by his coworkers. The nurse understands that this thinking is a

During an interview with a client who has a diagnosis of schizophrenia, the nurse notes that the client says, “My sister fun, car, swing, letter, orange, boat.” The nurse’s interpretation and diagnosis of this type of response would be to document

During a focused assessment on a client in a mental health setting, the nurse suspects magical thinking. What nursing observation would the nurse identify in a client demonstrating magical thinking?